OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Category I, CE c) Claimants re Report to Medical Provider (subset of "CE Forms Samples" category)

IC 179019 under ICR 202004-0960-001 · OMB 0960-0555.

Documents and Forms
Document Name
Document Type
Other-Sample of state DDS Claimant R
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Category I, CE c) Claimants re Report to Medical Provider (subset of "CE Forms Samples" category)
 
No Unchanged
 
Required to Obtain or Retain Benefits
 
20 CFR 404.1519 20 CFR 404.1518(c) 20 CFR 404.1613 20 CFR 404.1614 20 CFR 404.1624 20 CFR 416.903a 20 CFR 416.1024 20 CFR 416.912 20 CFR 416.913 20 CFR 416.914 20 CFR 416.917 20 CFR 416.919 20 CFR 416.1013 20 CFR 416.1014 20 CFR 404.1503a 20 CFR 404.1513 20 CFR 404.1514 20 CFR 404.1512 20 CFR 404.1517 20 CFR 416.918(c)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Sample of state DDS Claimant Report Letter/Form CE_c) Report to Med Provider - Revised.pdf No   Paper Only

Income Security General Retirement and Disability

 

450,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 450,000 0 0 0 0 450,000
Annual IC Time Burden (Hours) 37,500 0 0 0 0 37,500
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CE_c) Report to Med Provider - Current CE_c) Report to Med Provider - Current.pdf 06/13/2017
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.